The Maryland DHR form is an application for Long-Term Care and Waiver Medical Assistance, managed by the Maryland Department of Human Resources and the Maryland Department of Health and Mental Hygiene. This form is essential for individuals seeking financial support for long-term care services. To ensure your application is processed efficiently, gather the required documents and submit them promptly.
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The Maryland Department of Human Resources (DHR) and the Maryland Department of Health and Mental Hygiene offer a comprehensive application process for Long-Term Care and Waiver Medical Assistance. This application is crucial for individuals seeking financial support for long-term care services. To ensure a smooth application experience, applicants must gather a variety of documents, including proof of income, bank statements, and tax returns. The application requires detailed information about assets, including any property transfers that occurred within the last five years. Additionally, applicants need to disclose their current living situation, marital status, and any existing medical assistance benefits. It is important to apply promptly, even if all documentation is not immediately available, as the authorities will allow time to submit additional items. Understanding the requirements and preparing the necessary documents can significantly streamline the process and enhance the chances of approval.
Net Tangible Benefit Fannie Mae - Borrowers should consider both existing and new loan terms carefully.
Maryland Form 500 - Column 2 is for amounts as if no JCWAA or JGTRRA provisions were applied.
MARYLAND DEPARTMENT of HUMAN RESOURCES
MARYLAND DEPARTMENT of HEALTH and MENTAL HYGIENE
LONG-TERM CARE/WAIVER MEDICAL ASSISTANCE APPLICATION
Check List of Items Needed for Your Long-Term Care / Waiver Application
(Please keep this page for your records)
SEND PROOF If you do not already receive Long-Term Care Medical Assistance, we need the items listed below to process your application. Please send as many items as you can with this application. Please send copies, do not send originals. In some cases, we may need to request additional documents not listed below. If so, we will give you time to supply the additional documents.
DO NOT WAIT TO APPLY
If you do not have copies of all the documents listed, send in all the copies you do have when you apply. It is important to apply as soon as possible. We will give you more time to send additional documents needed.
If you or your spouse sold, traded, gifted, or disposed of any property, motor vehicles, stocks, bonds, cash or other assets in the past 5 years you will have to provide the following:
□ Type of asset
□ Reason for transfer
□ Value of asset
□ Who received the asset
□ Amount received for the asset
If you want to find out if your spouse can keep some of your monthly income, please provide:
□ Spouse’s gross monthly income
□ Property tax bill
□ Condo fees
□ Rent
□ Mortgage
□ Electric bill
□ Lot Rent
The following items are needed from you and your spouse to determine if you are eligible for Long-Term Care Medical Assistance:
□Federal Tax Returns for the current year and the preceding four years (please include all forms and schedules). A Record of Account can be obtained from the IRS free of charge by calling 1-800-908-9946 if your Federal tax returns cannot be located.
□Bank and Financial statements on all accounts owned and co-owned:
□Current Month (month of application)
□Previous Month (month prior to application)
□The last five years of the anniversary month of the application
□Current statement of retirement accounts
□Current statement of IRA or Keogh Accounts
□Current statements of:
□Stocks
□Bonds
□Money Market Funds
□Mutual Funds, Treasury, or Other Notes
□Certificates
□Current gross monthly income from all sources including:
□VA Pensions
□Railroad Retirement
□Pensions
□Annuities
□Face and cash value of Life Insurance policies (current annual statement)
□Current statement for burial accounts
□Burial Plot Deeds
□Life Estate Deeds
□Promissory Notes
□Mortgage Notes and Mortgage Deeds
□Trusts (including appendices, schedules, annual accountings, and amendments for the past five years)
□Private Health Insurance Cards including Medicare (copy of both sides)
□Health Insurance premium amounts
□Power of Attorney or Legal Guardianship Documents (if any)
Please continue by completely answering every question on the attached application. If you need more space to complete the application, please attach additional sheets.
DHR/FIA 9709 (REVISED 7-1-11)
Blank Page
MARYLAND DEPARTMENT OF HUMAN RESOURCES MARYLAND
DEPARTMENT OF HEALTH AND MENTAL HYGIENE LONG-TERM
CARE/WAIVER MEDICAL ASSISTANCE APPLICATION
Date Signed Application
Received in Local Department
MUST BE DATE STAMPED
FOR WORKER
USE ONLY
This part is for our
staff. Please continue
to Section A.
LDSS Office
Programs Applied For or
Assistance Unit IDs
Receiving
Client ID
Worker’s Name
Application Date
Program Medical Coverage Group
AU ID
SECTION A – BENEFIT SELECTION: Please tell us about which benefits you want and which benefits you already have.
I am applying for:
Long-Term Care Waiver
Do you need Medical Assistance for medical bills incurred in the past 3 months?
If yes, you will need to provide copies of the bills to your case manager.
YES NO
Tell us if you are currently receiving other assistance.
Icurrently receive:
Medical Assistance ID #
If you already receive Medical Assistance, please provide your ID number.
Cash Assistance
Food Stamps
Other, list:
If you receive any other benefits, please list all the benefits here.
SECTION B – APPLICANT INFORMATION: Please tell us about yourself.
Last Name
First Name
Middle Name
Suffix
Maiden Name or Other Name
(Jr., Sr., etc.)
Social Security Number:
Additional Social Security Number:
If you have a Social Security Number, enter it here.
If you have an additional Social Security Number, enter it here.
_
Date of Birth: (Month,Day,Year)
Gender:
Male
Female
Page 1 of 17
SECTION B – APPLICANT INFORMATION (continued)
Ethnicity
Optional
Race
1 – American Indian/Alaskan Native
1 – Hispanic or Latino
Optional –
2 – Asian
Please choose
3 – Black/African American
all race codes
2 – Not Hispanic or Latino
4 – Native Hawaiian/Pacific Islander
that apply to you.
5 – White
You do not have to give information about your race or ethnicity. If you do, it will help show how we obey the Federal Civil Rights Law. We will not use this information to decide if you are eligible. If you do not give us your race, it will not affect your application. The case manager will enter a race code for statistical purposes only. Title VI of the Civil Rights Act of 1964 allows us to ask for this information.
Are you a resident of Maryland?
YES
NO
Marital Status
Single
Married
Divorced
Separated
Widowed
Are you receiving Medical Assistance (Medicaid) benefits from another state?
If yes, please list the state:
Are you a U.S. Citizen?
If you answered NO, please complete SECTION C – IMMIGRATION STATUS, below.
What is your primary language?
Do you need an interpreter?
If you are not registered to vote,
would you like to receive a voter registration form?
Already registered to vote
SECTION C – IMMIGRATION STATUS (FOR NON-CITIZENS ONLY)
SEND PROOF Please send a photocopy of the front and back of your INS card.
What is your current INS
On what date did you receive
Are you a Sponsored
What is your Country of
Status?
your INS Status?
Immigrant?
Origin?
/
_/_
When did you enter the U.S.?
What is your INS Number?
If you are a refugee, please list your Refugee Resettlement
Agency:
_/
Page 2 of 17
SECTION D – CURRENT ADDRESS of HOME or INSTITUTION/LONG-TERM CARE
FACILITY: Please tell us about your Long-Term Care Facility, if you live in one.
If you live in a facility, what is the name of the facility?
On what date did you enter the facility?
_/ _/
What is your home address or the address of your facility?
Street
City
_ State
_ ZIP
Telephone #
Cellular Telephone #
Is this your mailing address? YES NO If you checked NO, please provide your mailing address information in Section V.
Do you (applicant/recipient) intend to return home?
Do you (applicant/recipient) intend to return home within 6 months?
SECTION E – PREVIOUS ADDRESSES: Please tell us where you have lived for the past
five years.
Did you or your spouse own
this home?
State
SECTION F – AUTHORIZED REPRESENTATIVE: Do you authorize someone to represent you in this application? If so, please tell us about your authorized representative.
(Jr., Sr., III, etc.)
Address
_ZIP
Page 3 of 17
SECTION F – AUTHORIZED REPRESENTATIVE (continued)
Home Telephone #
Work Telephone #
What is the authorized representative’s relationship to you?
If answer is spouse, please complete the next question:
Do you or your spouse own this home?
If Authorized Representative is your spouse, please provide spouse’s Social Security Number:
SECTION G – SPOUSAL INFORMATION: Please tell us about your spouse. Leave this section blank if your spouse is listed as your Authorized Representative in Section F.
Spouse’s Social Security Number
Do you or your spouse own
SECTION H – DISABILITY: Please tell us about your disability, if you have one.
Are you disabled?
If yes, when did the disability begin?
What is your disability?
Premium Amount
Do you receive Medicare Part A?
$
Do you receive Medicare Part B?
SEND PROOF
Please send
verification of the premium
Do you receive Medicare Part C?
amounts you pay
Do you receive Medicare Part D?
If yes, please provide your Medicare Claim Number:
Page 4 of 17
SECTION I – VETERAN INFORMATION: If you are a veteran, a disabled widow(er), or a disabled child of a deceased veteran, fill in this section:
SEND PROOF Please send a photocopy of the front and back of your military service card.
Veteran’s Name
Relationship to Veteran
Veteran’s Status
Military Service Number
SECTION J – MEDICAL INSURANCE: If the applicant/recipient is insured, fill in this section: If you have more than one policy, place additional information in Section V.
SEND PROOF Please send a photocopy of the front and back of your insurance card(s) and verification of the premium amounts you pay.
Policy Number
Group Number
Policy Holder Name
Relationship to Policy Holder
Policy Effective Dates
From:
To:
Policy Holder Address
ZIP
Telephone
Insurance Company
Insurance Company Name
Union
Union Local
Union Name
Number
Page 5 of 17
SECTION K – INCOME FROM WORKING: Please tell us about any income you or your spouse are currently receiving from working, including any sick leave payments.
SEND PROOF Please send copies of any proof of pay, such as a paystub. If you need additional space to complete this section, please use Section V or attach additional sheets.
Employer Name
Type of Job
Employer Address
State_
Date Job
Gross Wages per Pay Period, including tips and
Began_
Ended_
commissions.
per
Hours per Pay Period
How often do you get
If the job has ended, what is your last expected pay date?
paid?
Weekly
Biweekly
Monthly
SECTION L – YOUR BENEFITS AND OTHER INCOME: Please tell us about any income or benefits that you are receiving, have applied for, or have been denied.
SEND PROOF Please send current copies of statements that verify the gross amount of income you receive.
TYPE OF BENEFIT
RECEIVING INCOME
AMOUNT
APPLICATION
APPLICATION DATE OR
OR INCOME
OR BENEFITS?
STATUS
DENIAL DATE
Social Security
Please write your claim number:
Applied for
Denied
Black Lung Benefits
SSI (Supplemental Security
Income)
Veteran’s Pension/Benefits
Pension or Retirement
Civil Service Annuity
Railroad Retirement Benefits
Alimony
Page 6 of 17
SECTION L – YOUR BENEFITS AND OTHER INCOME (continued)
Worker’s Compensation
Disability/Sick Benefits
Union Benefits
Unemployment Benefits
Lump Sum Cash Amounts
Interest/Dividends from Stocks,
Bonds, Savings, or other
investments
Business Income
Other (e.g., Rental Income, or
Compensation from a Legal
Settlement)
Other
Please describe:
SECTION M – ASSETS: Please tell us about your assets as of the first day of this month. Check YES or NO for each ASSET TYPE. If you check YES, fill in the other boxes. List all assets owned by you or your spouse individually, jointly, or with other persons. If you have more than one asset of the same type, use the “Other” boxes at the bottom of the list.
SEND PROOF Please send copies of current statements that verify the value of the assets.
ASSET TYPE
CHECK ONE
OWNER
ACCOUNT NUMBER
INSTITUTION NAME
Cash on Hand
Checking Account
Savings Account
Credit Union Account
Trust Fund
IRA or Keogh
Account
Other Retirement
Accounts
Stocks and Bonds
Page 7 of 17
SECTION M – ASSETS (continued)
Treasury or Other
Notes
Annuity
Ownership in a
Company
Patient Fund Account
SECTION N – OTHER ASSETS: Please tell us about any other assets you own and assets jointly owned with other individuals. This could include livestock, recreational vehicles, or any other property of value such as collections of antiques, coins, jewelry, or stamps.
SEND PROOF Please send copies of current statements or documents that establish the fair market value of the asset(s) as well as the amount owed.
CURRENT FAIR MARKET VALUE
CURRENT AMOUNT OWED
OWNER(S)
SECTION O – POTENTIAL ASSET OR INCOME: Please tell us about any accident settlement, trust fund, inheritance, or any other money, property, real property, or assistance you expect to receive.
SEND PROOF Please send copies of current statements or documents that describe the nature, amount, and payment schedule of the asset.
Asset Type
Lawyer Name
Page 8 of 17
Understanding the Maryland DHR form can be challenging, and there are several misconceptions that often arise. Here are five common misunderstandings, along with clarifications to help you navigate the application process.
Many people believe they need to gather every document listed before submitting their application. In reality, it’s crucial to apply as soon as possible. You can send in the documents you have and provide additional ones later.
Some individuals think that only those currently receiving assistance can apply for Long-Term Care Medical Assistance. However, anyone in need of these services can submit an application, regardless of their current assistance status.
While the application form may seem simple, the process can take time. It often requires thorough documentation and may involve follow-up requests for additional information from the case manager.
Some applicants believe they need to report every single asset, no matter how small. In fact, only significant assets, such as property or investments, need to be disclosed. It's important to focus on the relevant items that could impact eligibility.
There is a common belief that having a spouse disqualifies you from receiving assistance. This is not true. The form allows for consideration of your spouse’s income and assets, which can affect the amount of assistance you receive, but it does not automatically disqualify you.
When completing the Maryland DHR form for Long-Term Care/Waiver Medical Assistance, applicants often make several common mistakes that can delay the processing of their application. One frequent error is failing to provide all required documentation. The form specifies various documents needed, such as tax returns, bank statements, and proof of income. Without these documents, the application may be considered incomplete, resulting in unnecessary delays.
Another mistake is submitting original documents instead of copies. The instructions clearly state that applicants should send copies of their documents. Sending original documents can complicate the process, as the agency may not return them. It is crucial to follow this guideline to ensure that the application is processed smoothly.
Inaccurate or incomplete information is also a significant issue. Many applicants overlook sections of the form or provide incorrect details, such as Social Security numbers or income amounts. These inaccuracies can lead to confusion and may require additional follow-up, which can prolong the application process. It is essential to double-check all information before submission.
Some applicants neglect to answer all questions on the form. Each section is designed to gather specific information necessary for determining eligibility. Leaving questions unanswered can raise red flags and may result in a request for clarification or additional information, further delaying the review of the application.
Finally, applicants often miss the importance of timely submission. The form encourages individuals to apply as soon as possible, even if they do not have all required documents ready. Waiting to gather every item before submitting can lead to missed deadlines for assistance. It is better to send in what is available and provide additional documents later, as the agency will allow time for this.
The Maryland Department of Human Resources (DHR) form is an essential document for individuals applying for Long-Term Care or Waiver Medical Assistance. However, several other forms and documents often accompany this application to ensure that all necessary information is provided. Here’s a brief overview of these important documents.
Gathering these documents can seem overwhelming, but they are vital for a successful application process. By preparing them ahead of time, applicants can streamline their experience and ensure they meet all necessary requirements for Long-Term Care Medical Assistance in Maryland.
The Maryland DHR form shares similarities with the Supplemental Nutrition Assistance Program (SNAP) application. Both documents require applicants to provide comprehensive personal information and financial details to determine eligibility for assistance. Just as the DHR form requests proof of income, assets, and expenses, the SNAP application requires information about household income and expenses to assess eligibility for food assistance. Additionally, both forms emphasize the importance of submitting documentation promptly to avoid delays in processing applications, underscoring the necessity of timely assistance for applicants in need.
Another document akin to the Maryland DHR form is the Temporary Assistance for Needy Families (TANF) application. Similar to the DHR form, the TANF application gathers extensive information about the applicant's financial situation, including income, assets, and household composition. Both applications aim to ensure that the resources are directed to those who genuinely require assistance. Furthermore, they both include sections that allow applicants to list any other benefits they are currently receiving, which helps streamline the evaluation process and prevent duplication of assistance.
In the context of required documentation for various assistance programs, it's essential to highlight the legalities entailed in firearm transactions as well. For instance, the proper use of a Bill of Sale for a Gun can serve to protect both parties involved in the sale, ensuring that all details are meticulously recorded to avoid any potential legal issues in the future.
The Medicaid application also bears resemblance to the Maryland DHR form. Both documents require applicants to furnish detailed financial records, including bank statements and tax returns, to establish eligibility for medical assistance. The Medicaid application, like the DHR form, emphasizes the importance of submitting copies of documents rather than originals, ensuring that applicants can retain their important records. Additionally, both forms address the need for applicants to report any changes in their financial status promptly, which can impact their eligibility for benefits.
Lastly, the Social Security Disability Insurance (SSDI) application is another document that parallels the Maryland DHR form. Both forms necessitate the collection of personal and financial information to determine eligibility for assistance. The SSDI application specifically requires medical documentation of disabilities, while the DHR form focuses on financial eligibility for long-term care. However, both applications share the common goal of providing support to individuals in need, ensuring that necessary assistance is delivered in a timely manner. The emphasis on thorough documentation and prompt submission is a key feature shared by both forms.